Pharmacy Sheet

Click here to download a PDF of the Pharmacy Sheet or fill out the online form below.

  • Due to the high cost of prescriptions and medical equipment, we want to be sure that your prescriptions for medication and/ or medical equipment are sent to your insurance authorized pharmacy or home care company. For that reason, we ask that you complete this form entirely and bring it to your appointment.

    We understand that you may not have prescriptions for medications and/or home medical equipment currently; however, if you were to be prescribed any in the future, this information is very important to us.
  • ( If you are not sure please call your insurance to find out which Durable Medical Equipment Company is covered.)
  • Examples of Home Care Companies include but are not limited to:
    • Apria
    • Agnesian
    • Aurora VNA
    • Bel-Regional (Bellin Home Health)
    • Erickson’s
    • Great Lakes Home Medical
    • GBHME
    • Lincare
    • Thedacare at Home
    • Bayside Home Medical